Absent external oblique musculo-aponeurotic complex during inguinal hernioplasty: a case report and review of literature

Abstract

The external oblique musculo-aponeurotic complex is an important contributor to the strength of the inguinal canal. The present case report describes the bilateral absence of the external oblique muscle in a patient. A 40-year-old male patient presented with a history of intermittent lower abdominal pain for 15 years which had increased over the past 2 years. Abdominal examination revealed bilateral reducible, incomplete, direct inguinal hernia. Elective bilateral Lichtenstein's mesh hernioplasty was planned for the patient. Intraoperatively, there was no evidence of the external oblique aponeurosis and the spermatic cord was noted deep to the membranous fascial layer. The inguinal ligament was thin and atrophic and was attached to the pubic tubercle medially and anterior superior iliac spine laterally. There was no evidence of any superior aponeurotic connection to the inguinal ligament. A postoperative ultrasound examination of the abdomen confirmed the bilateral absence of the external oblique musculo-aponeurotic complex. The isolated absence of the external oblique musculo-aponeurotic complex in adults is an exceedingly rare anomaly. The possibility of such an anomaly should be considered in patients without other risk factors for hernia.

Unilateral absence of external oblique musculo-aponeurotic complex during routine inguinal hernia repair

“…No mention was made about the presence of the inguinal ligament. In another case of bilateral absence of external oblique musculoaponeurotic complex, there was no abnormality of the transversus abdominis or the transversalis fascia, and a weak, thin inguinal ligament was observed bilaterally [9] . Our case was similar to this one, except that the problem was unilateral.…”

“…To the best of our knowledge, there have been only two case reports on the absence of the external oblique encountered during inguinal hernioplasty [5] , [9] . One patient was an obese male who presented with bilateral inguinal hernia along with an incisional hernia through the postoperative scar of an appendectomy performed earlier.…”